gastrointestinal Flashcards
if a pt has primary sclerosing cholangitis, what would indicate a decrease in the synthetic function of the liver and the need for a liver transplant
prolonged PT
which demographic and syndrome is primary biliary cholangitis associated with
middle aged females
sjogrens syndrome
what is Wilsons disease and what is it characterised by
hepatic jaundice due to excessive copper deposition in liver / brain / cornea
characterised by
- reduced serum caeruloplasmin
- reduced total serum copper
causes psychiatric problems - speech/swallowing/physical coordination
which clinical sign is associated with raised oestrogen in cirrhosis
palmar erythema
which clinical sign is associated with portal hypertension in cirrhosis
caput medusae
what is terlipressin used for
treatment of bleeding oesophageal varicies
what is the cause of jaundice in the presence of deranged liver function tests and anti mitochondrial antibodies
primary biliary cholangitis
what is given before the administration of glucose in wernickes encepahlopathy
IV thiamine
what is used when there’s reduced consciousness due to cerebral oedema in hepatic encephalopathy
IV mannitol
what helps to reduce encephalopathy by facilitating nitrogenous waste loss through the intestines
lactulose
what is used to reduce oedema or ascites in liver cirrhosis
spironolactone
what are the most common bacteria associated with spontaneous bacterial peritonitis
e coli
k pneumoniae
prophylactic treatment for spontaneous bacterial peritonitis
Abx: ciprofloxacin or norfloxacin
what s the initial investigation if see someone unstable and confused, smelling of alcohol and has signs of liver failure
blood glucose - to rule out hypoglycaemia
then do LFTs
What is disulfiram used for
Is an aldehyde dehydrogenase inhibitor used in patients with alcohol dependency
Causes unpleasant symptoms on alcohol consumption which helps them abstain from drinking
If a patient has hepatic encephalopathy which medication can reduce confusion
Lactulose
- chlordiazepoxide is for pts at risk of alcohol withdrawal and is CONTRAINDICATED in pts with hepatic encephalopathy
what is Gilbert’s disease
benign condition (no treatment needed) in which there is decreased activity of the enzyme that conjugates bilirubin
this means you get unconjugated hyperbilirubinaemia during fasting, stress, exercise, illness
likely diagnosis if someone gets jaundice in ramadan
gilbert’s disease
what is the most common complication of acute liver failure
bacterial infection
which antibiotics should be avoided when treating HAP in a pt with acute liver failure and why
gentamicin - can cause renal failure
which resp condition requires needle decompression
tension pneumothorax
when would you give FFP
if there is evidence of haemorrhage / bleeding
when is IV mannitol given
if suspected raised intracranial pressure
treatment if pt has bibasal crepitations on inspiration
IV furosemide - as they have pulmonary oedema
which symptom specifically indicates primary biliary cirrhosis
pruritus
which antibiotic can cause jaundice
co amoxiclav
what does dry cough and red nodules on shin indicate
sarcoidosis
what does the triad of abdominal pain, ascites, tender hepatomegaly indicate
Budd Chiai syndrome - thrombosis of hepatic vein
what is the most likely diagnosis for an older pt presenting with anaemia, dyspnoea, palpitations, headaches, easy bruising, bone pain, splenomegaly
myelofibrosis
main treatment for confusion due to hepatic encephalopethy
ORAL lactulose
what is given for symptomatic relief of alcohol withdrawal
chlordiazepoxide
what is given to prevent wernickes encephalopathy
IV thiamine
what does a cloudy ascitic fluid tap indicate
infection
an INR over which number is indicative alone for urgent liver transplant
INR > 6.5
what is the triad of acute liver failure
encephalopathy
jaundice
coagulopathy
what causes leuchonychia in chronic liver disease
hypoalbuminaemia
what causes excoriations/pruritis in chronic liver disease
raised serum bilirubin
what ammonia levels are seen in liver failure
high
medication used to reduce recurrence of hepatic encephalopathy
rifaximin
3 meds for hepatic encephalopathy and what they’re used for
oral lactulose - for confusion, causes loss of toxins via gut
IV mannitol - for reduced consciousness, reduces ICP
rifaximin - for prevention of recurrence
pruritus + pale stool + dark urine = what kind of jaundice
obstructive jaundice
iif a pt has jaundice and breathlessness (but no smoking history and bronchodilators are ineffective) what os the most likely cause
low serum alpha 1 antitrypsin
describe the microscopy results of ascitic tap for SBP
neutrophil count > 250 /uL
treatment for SBP
IV ceftriaxone / ciprofloxacine / cefotaxime
how many hours after abstinence from alcohol does delirium terms occur
48 - 72 hrs
what are the LFTs and other blood results for alcoholic hepatitis
AST>ALT (2:1)
elevated GGT
non megaloblastic macrocytic anaemia
increased ALP (but less than ALT and AST)
increased bilirubin
decreased albumin
increased PT
if have a pt who smells of alcohol, has signs of chronic liver disease and seems very confused, what’s the first investigation
blood glucose to rule out hypoglycaemia , then do LFTs
symptomatic relief of alcohol withdrawal
chlordiazepoxide
vitamin C
prevention of wernickes encephalopathy
pabrinex (IV thiamine)
what medications are given following successful alcohol withdrawal
Acamprosate - for abstinence
Disulfiram
Naltrexone
which autoimmune hepatitis occurs in children only
type 2
what is the most common type of autoimmune hepatitis
type 1
antibodies for type 1 A.I hepatitis
anti smooth muscle antibodies (ASMA)
anti nuclear antibodies (ANA)
antibodies for type 2 A.I hepatitis
anti liver kidney microsomal 1 antibodies
(anti LKM1)
antibodies for type 3 A.I hepatitis
anti soluble liver antigen
what is a sensitive markers for ischaemic hepatitis
significant rise in LDH
what is the highest LFT in viral hepatitis
ALT (ALT >AST)
describe the serology results in AI hepatitis
high IgG (hypergammaglobulinaemia)
ANA / ASMA / A-LKM1 / anti-solube liver antigen antibodies
which hepatitis is characterised by high IgG
auto immune hepatitis
treatment for AI hepatitis
Induction therapy : prednisolone (corticosteroid)
Maintenance therapy : azatioprine (immunosuppressant)
which hepatitis present predominantly in young/midddle aged women
autoimmune hepatitis
with class of antibody indicates previous or chronic infection
IgG
which class of antibody indicates current / acute infection
IgM
most common viral hep in developing countries
hep A
most common viral hep globally
hep B
causes of viral hepatitis
ABCDE ACE
Hep A
Hep B
Hep C
Hep D
Hep E
Adenovirus
CMV
EBV
what virus causes hep a / b /c / e
Hep A = RNA picarnovirus
Hep B = hepadnavirus
Hep C = RNA flavivirus
Hep E = calcivirus
which hep virus is asymptomatic
hep c
with which hep virus do most people develop chronic infection
hep c
hep a / b / c mode of transmission
a = faecal - oral
b = blood/body fluids
c = blood/body fluids
with which hep virus do most people develop jaundice
hep a
(some adults do with hep b, hep c is usually asymptomatic)
what is the serology of someone with chronic hep b infection with high viral replication
positive anti HBcIgG antibodies
positive hepB antigen
positive HBeAg
positive HBsAg
which Hep B antibody indicates previous vaccination
antibody against HbsAg
which Hep B antibody indicates previous infection
IgG antibody against HbcAg
which Hep B antigen indicates high infectivity / high viral replication
HbeAg
1st and 2nd line treatment for hep B
1st = Peginterferon, alpha 2a
(interferon alpha)
2nd = Tenofovir, Entecavir
treatment for hep c
DAAT
nucleoside analogues eg sofosbuvir+ ribavirin
characteristic symptoms of ascending cholangitis
charcots triad
RUQ pain
Fever
Jaundice
what is fibrosis
fibrosis of liver tissue into regenerative nodules
what causes palmar erythema in cirrhosis
increased oestrogen
what causes leuchonychia in cirrhosis
low albumin
what causes caput medusae in cirrhosis
portal HTN
what is fetor hepaticus and what is it a sign of
rotten eggs/garlic smelling breath
sign of liver cirrhosis
clinical signs of liver cirrhosis
palmar erythema
dupuytren contracture
caput medusae
spider naevi
fetor hepaticus
pruritus
plantar erythema
gynaecomastia
jaundice
oesophageal varices
oedema
ascites
splenomegaly
smaller liver
what is the most specific and sensitive test for liver cirrhosis
liver biopsy
what is done in liver cirrhosis every 6 months to screen for hepetocellular cancer
liver ultrasound
AFP levels
what is done to check for varicies in pts with liver cirrhosis
upper GI endoscopy
how to mange ascites due to liver cirrhosis
sodium restriction
spironolactone
paracentesis
what surgical procedure can treat portal hypertension to reduce the risk of oesophageal varices
TIPS (transoesophageal intrehepatic porto systemic shunt)
what treatments are required if a pt with liver cirrhosis has haematemesis / malaena
terlipressin (vasopressin analogue)
IV Abx
Vit K / FFP (PT>20) / blood or platelet transfusion
what med is used as a prevention to reduce recurrence of hepatic encephalopathy
rifaximin
triad of liver failure
coagulopathy (INR > 1.5)
jaundice
encephalopathy
what treatment is given for paracetamol overdose leading to liver failure
N -acetylcysteine
what does asterixis in liver failure indicate
hepatic encephalopathy
prophylactic Abx for SBP
ciprofloxacin or norfloxacin
how long after last drink does delirium tremens occur
48-96 hours
which tumour marker is used for hepatocellular carcinoma
AFP
what is the most likely diagnosis of someone with COPD and liver cirrhosis
alpha - 1 - antitrypsin deficiency
what is the number of units per day and the audit score baseline for recommending assisted alcohol withdrawal (eg chlordiazepoxide)
over 15 units per day
AUDIT score of over 20
what type of bilirubin is high in gilbert’s syndrome
unconjugated bilirubin
what do you measure to confirm diagnosis of Wilsons disease
ceruloplasmin levels
likely diagnosis in a 22 year old with jaundice, tremor, affected speech
Wilsons disease
what is a subacute history with tender hepatomegaly and ascites suggestive of (pt has had no recent travel and doesn’t drink)
liver ischaemia due to budd chiari syndrome
investigation for Budd chair syndrome / liver ischaemia
US liver with Doppler flows
what is the serum copper level in Wilsons disease
LOW - bc copper is deposited the tissues
what vitamin deficiency causes wernickes encephalopathy
vitamin B1 (thiamine)
triad of werncikes encephalopathy
ataxia
confusion
opthalmoplegia
first line treatment for Wilsons disease
penicillamine
(remember like “copper Penny”)
what is the LFT results for AI hep
raised ALT and AST compared with ALP
which type of bilirubin can be found in the urine
conjugated bilirubin - as this is water soluble
which type of bilirubin is high in Gilberts syndrome
unconjugated bilirubin - only yellow skin and sclera not poo/pee
which gene mutation is responsible for Gilberts syndrome
UGT1A1 gene
initial step if pt took paracetamol overdose more than 15 hours ago
start N acetyl cysteine immediately
initial step if pt took paracetamol overdose 4 - 15 hours ago
check blood paracetamol conc and commence treatment accordingly
what are the 3 situations where you should start N acetyl cysteine immediately for paracetamol overdose
- staggered overdose
- if ingestion was more than 15 hours ago
- if there is uncertainty about timing
pathophysiology of delirium tremens
unopposed glutamate activity
what is the LFT results in non alcoholic fatty liver disease
mild increase in AST and ALT
how do you diagnose non alcoholic fatty liver disease
liver biopsy
what is Budd chiari syndrome
obstruction of hepatic veins (often by thrombosis)
- hepatomegaly
- ascites
- abdo pain
for paracetamol ingestion, what Ph would indicate immediate liver transplant
pH < 7.3 at 24hrs post ingestion
what is naloxone used for
to treat and reverse opioid toxicity
how do you reduce risk of renal impairment in pts with SBP
give HAS (human albumin solution)
give 2 contraindications to performing an ascitic tap
infection on skin overlying area intended to insert needle into
disseminated intravascular coagulopathy
how do you calculate SAAG (serum-ascites albumin gradient)
serum albumin - ascites albumin
what are the causes of ascites if SAAG > 11 g/L and what type of ascites is it
ascites is transudative (low albumin)
causes:
portal HTN
liver cirrhosis
alcoholic liver disease
liver failure
Budd-Chiari syndrome
congestive heart failure
what are the causes of ascites if SAAG < 11 g/L and what type of ascites is it
ascites is exudative (high protein)
causes:
MIPN
- malignancy / malnutrition
- infection (eg TB)
- pancreatitis
- nephrotic syndrome
treatment for ascites
dietary sodium restriction
spironolactone
ascitic tap / paracentesis (give Iv albumin when doing large volume paracentesis)
AbX for SBP prophylaxis (ciprofloxacin / norfloxacin)
2 main side effects of spironolactone
gynaecomastia and hyperkalemia
wheat do you give for ascites if the max dose of spironolactone isn’t working
add furosemide to the spironolactone
what to give during large volume paracentesis
IV albumin
initial investigation of ascites
abdo USS
sign on examination suggesting ascites
shifting dullness
treatment of oesophageal varices due to portal HTN
terlipressin + IV Abx
consider TIPS (transjugular intrahepatic portosystemic shunt)
Prophylactic Beta blockers
what is raised in ascitic tap for SBP
neutrophils
what suggests SBP in an ascitic tap
ascitic fluid white cells > 250/mm3 which are predominantly neutrophils (PMN - polymorphonuclear neutrophils)
or
ascitic fluid contains neutrophils > 250/mm3 neutrophils
what is raised in ascitic tap for intra abdominal malignancy
lymphocytes
what is constipation defined as
irregular bowel movements
=< 3 bowel movements per week
give 3 groups of medication that cause consitpation
CCBs
antipsychotics
opiates
what is primary and secondary constipation
primary = due to dehydration, low fibre diet, lack of exercise
secondary = due to diverticulosis, diverticulitis, haemorrhoids, bowel obstruction, IBS etc
treatments for consitaption
1st: dietary and lifestyle modifications (more fluids, fibre exercise)
Bulk laxatives and tool softeners
Osmotic laxatives - eg lactulose
stimulant laxatives - eg senna
prunes - natural laxatives
what are the 4 main types of laxatives
bulk laxatives
osmotic laxatives
simulant laxatives
stool softener laxatives
when might constipation cause confusion
faecal impactation
bristol stool chart (type 1 -7)
1 - hard lumps, like nuts
2 - sausage shape but lumpy
3 - sausage shape with cracks on surface
4 - smooth sausage
5 - soft blobs, clear cut edges
6 - fluffy pieces, ragged edges, mushy
7 - watery, no solid pieces
investigations for constipation
anal manometry
FBC - ion deficiency anaemia
TFTs - hypo thyroidism
AXR - rectal mass, faecal impactation
Rome IV diagnostic criteria for functional constipation in adults
- at least 2
- in the past 1/4 or more of defections
- in past 12 weeks
- with symptoms ongoing for 6+ months
- 3 or less bowel movements per week
- sensation of incomplete evacuation
- sensation of anorectal obstruction / blockage
- manual aid to evacuate stool
- straining attempts to defecate
- hard/lumpy stool
constipation red flags in children
meconium passage delayed (over 48 hours)
consitpation within first month of life
bilious vomiting
blood in stool
fever
family history of related disease
severe abdo distention
constipation red flags in adults
family history
iron deficiency anaemia
blood in stool
palpable ado mass
reduced stool caliber
weight loss
recall prolapse
sudden onset
unresponsive to medication
>50 years
what counts as chronic anal fissure
over 6 weeks
primary vs secondary anal fissure
primary - due to local trauma
secondary - due to underlying disease eg previous anal surgery, IBD, infections
acute anal fissure management (<1 week)
conservative
- fluids
- diet modifications
- bulk forming laxatives and stool softeners
- lubricant / petroleum jelly application prior to defacation
- sitz bath
chronic anal fissure (>6 weeks)
analgesia
- topical GTN
- topical diltiazem
for persistent fissures
- botox
or surgical sphincterectomy
grades I - IV for internal fissures
I - bleeding, no prolapse
II - prolapse, reduces spontaneously
III - prolapse, can be technically reduced
IV - prolapse, cannot be reduced
internal vs external sphincter
internal - above denate line, painlesss
external - below denate line, can be painful and prone to thrombosis
how can you tell if a haemorrhoid is thrombosed
v painful
purple
oedematous
1st line diagnostic investigation for haemorrhoid
anoscopic examination (protoscopy)
1st line management for all haemorrhoid patients
dietary and lifestyle modifications
management for haemorrhoid grades I - IV
I = topical corticosteroids (relives pruritis)
II-III = Rubber band ligation
IV = surgical haemorrhoidectomy
which class of proteins triggers coeliac disease
gliadin
which skin manifestation is seen in coeliac disease
dermatitis herpetiformis
(itchy papulovesicular lesions on extensor surfaces of skin esp elbows)
1st line and gold standard diagnostic investigations for coeliac disease
1st line : serology
- increased IgA tTG / anti-endomysial / anti-gliadin antibodies
after that do Endoscopy + biopsy (diagnostic, gold standard)
- crypt hyperplasia / villous atrophy / increased intraepithelial lymphocytes
treatment for coeliac disease
avoid gluten - eat alternatives
vitamin and mineral supplements (as coeliac disease causes malabsorption)
which vaccination is give to those with coeliac disease and why
pneumococcal vaccination
they get functional hyposplenism
FBC finding for coeliac disease
iron deficiency anaemia
Blood smear finding for coeliac disease and what does this indicate
target cells
Howell-jolly bodies
indicates functional hyposplenism
what effect does coeliac disease have on the spleen
causes functional hyposplenism
most important sign suggestive of IBS
pain relieved by defecation
which extra intestinal manifestation runs its course independent of IBD activity (active luminal disease)
primary sclerosing cholangitis
what medication is used to maintain remission in UC in those who’s remission is not maintained by 5 ASA
mercatopurine or azothioprine
what investigation is done to monitor for complications of coeliac disease
DEXA scan –> monitors for osteoporosis / osteopenia
which area is always affected in UC but often spared in crohns
rectum
what type of laxative is macrogol
osmotic
what is the first line investigation for coeliac disease in a pt who his IgA deficient
blood test for anti tTG IgG antibodies
(normally its for anti tTG IgA antibodies)
first lien med for crohns flare up
IV hydrocortisone
pt with crohns presents with pain and fresh red bleeding on defecation. what is the most likely diagnosis
anal fissure
which part of the intestine is affected by crohns disease and contributes to the formation of gallstones
terminal ileum
what is imatinib used to treat and what is its mechanism of action
chronic myeloid leukaemia
GI stromal tumours
inhibition of tyrosine kinase
which investigation differentiates IBS from IBD
faecal calprotein
what does positive faecal elastase indicate
chronic pancreatitis
what do cysts on stool microscopy indicate
parasitic infection eg giardiasis
what type of condition does high ALP compared to ALT/AST indicate
obstruction
what does jaundice, pruritis and an obstructive LFT pattern in a pt with UC indicate
primary sclerosis cholangitis
LFT results in PSC
obstructive pattern
- v high ALP compared to AST/ALT
MRCP results in PSC
multiple beaded biliary structures
what do you need to rule out if someone with coeliac disease presents with weight loss / recurrent diarrhoea / recurrent abdominal pain
enteropathy associated T cell lymphoma
treatment for PSC
- supportive
- liver transplant, is potentially curative but PSC can recur
which condition does pain relieve by defecation indicate
IBS
pt with opiate - induced constipation has been taking movicol (osmotic laxative) to no effect. what is next step in management
ADD Senna
best treatment for opiate-induced constipation
a combination of an osmotic and a stimulant laxative
in which pts should stimulant laxatives be avoided
pts with
- small bowel obstruction
- IBD
- pregnant
initial management in a euvolemic pt with toxic megacolon
urgent decompression with an NG tube
which conditions is hcg raised in
hydatidiform moles
choriocarcinoma
gestational trophoblastic tumours
what is VMA (vanillylmandelic acid) raised in
phaechromocytoma
which condition is CA19-9 raised in
cholangiocarcinoma
which condition is CA125 raised in
ovarian cancer
what do raised faecal leukocytes indicate
bacterial infective colitis
what is a common defecation problem in enterally fed pts
diarrhoea
what is the likely diagnosis if a pt with long-standing UC develops abnormal liver enzymes and weight loss
cholangiocarcinoma / biliary tract carcinoma
crohns pt is on steroid therapy, which med should she be put on to prevent crohns flare
azothioprine
pt underwent a bowel resection for their crohns and is now suffering with pale coloured and difficult to flush diarrhoea. what is most likely diagnosis
short bowel syndrome
what is blepharitis and what is it most commonly caused by
inflammation of eyelid - red, crusty
caused by staph aureus infection
when is tacrolimus used to treat UC
when pt is resistant to aminosalicylates and steroids
what is used to maintain remission in UC pts
azathioprine
if pt has an acute uC flare up and topical +oral mesalazine is not improving symptoms what do you add
add prednisolone
what medication is used to maintain remission in both uc and crohns
azathioprine
if colonscopy is normal in a pt with crohns, whats the next step in investigation
investigate the small bowel:
- small bowel MRI or small bowel capsule endoscopy
what is loperamide used for
to treat diarrrhoea
so don’t give in constipation !!
give some iatrogenic causes of diarrhoea
oral magnesium replacement, penicillin, omeprazole, metformin, chemotherapy, NSAIDs
most likely cause of hairy-looking white lesion on side of tongue
epstein barr virus
likely diagnosis if a pt presents with weight loss, bloody diarrhoea, high ALP and positive p-ANCA and ANA
primary sclerosing cholangitis (secondary to UC)
what are sore swollen tongue (glossitis), bleeding gums and peripheral neuropathy a sign of
B12 deficiency
order of treatments for UC flare up
- IV hydrocortisone
- cyclosporin
- infliximab
- colectomy
first line test for coeliac disease suspicion
total IgA + IgA tTG
if crohns pt presents with sepsis secondary to a perineal abscess, what is first line of investigation
urgent MRI pelvis
(if delay - urgent CT, if not possible - examination under anaesthetic)
what kind of laxative is ispaghula husk
bulk forming
what kind of laxative is macrogol
osmotic laxative
what kind of laxative is bisacodyl
stimulant laxative
what is a likely diagnosis for abdominal pain, explosive diarrhoea, bloating and flatulence after tropical travel
giardia
what do pale stools (steatorrhea) indicate
malabsorption
if a pt meets IBS criteria, what is the most appropriate next investigation
tTG antibodies, to rue out coeliac disease
what indicates surgery with toxic megacolon
not responds to steroids within 48-72 hrs
toxic megacolon treatment
NBM
IV fluids
IV hydrocortisone
which cause if diarrhoea shows ancathocytes, target cells and Howell jolly bodies on a a blood film
coeliac disease
in which conditions should pts also be tested for coeliac disease
graves disease
T1DM
first line treatment for flare up in crohns
prednisolone
what is shilling test used for
evaluates whether or not vit B12 deficiency is caused by pernicious anaemia
treatment for dermatitis herpetiformis
dapsone
what do aphthous ulcers in the context of weight loss and abdo pain indicate
crohns
if pt is in an acute condition/having a flare up and was suspected to have IBD (blood in stool is already seen), what is the best diagnostic investigation
flexible sigmoidoscopy
(colonoscopy can cause perforation in flare up)
what is chlorhexidine used to treat
oral ulcers
what is fluconazole used to treat
oral thrush , candidiasis
what is the ABC of IBS
abdominal pain, bloating, change in bowel habit for at least 6 months
rome IV criteria for IBS
on average at least 1 day/week, during past 3 months, 2 of the following
- pair related to defecation
- change in stool frequency
- change in stool form/appearance
according to NICE, those who meet criteria for IBS should be tested to rule out which other condition
coeliac disease - test for anti tTG antibodies
management for cramps/pains associated with IBS
antispasmodics
management for constipation dominant IBS
bulk forming laxatives (ispagula husk / Fybogel)
avoid lactulose
management for diarrhoea dominant IBS
Loperamide (antidiarrhoeals)
where is the pain in UC
left lower abdomen
where is the pain in crohns
right lower abdomen
contrast the diarrhoea in UC vs crohns
UC: bloody, mucus
Crohns: non bloody, watery
contrast the main symptoms a right vs left sided colorectal carcinoma
right: melena, diarrhoea
left: constipation
contrast colon layer involvement in UC vs crohns
crohns: transmural
UC: mucosa
contrast the most commonly affected parts of gut in UC vs crohns
Crohns: terminal ileum
UC: rectum
contrast granuloma involvement in UC vs crohns
crohns: non caseating granulomas
UC: no granulomas
contrast involvement pattern in UC vs crohns
crohns: skip lesions
UC: continuous
contrast smoking effects in UC vs crohns
crohns: smoking = Risk factor
UC: smoking = protection
contrast joint involvement in UC vs crohns
crohns: arthropathy (joint pain)
UC: ankylosing spondyliis, pyoderma gangernosum
what are the effects on the skin and eyes in UC and crohns
skin:
erythema nodosum (erythema on shins)
pyoderma gangrenosum (ulcers on legs)
mouth ulcers
eyes:
anterior uveitis (painful red eye with loss of vision and photophobia)
episcleritis (painless red eye)
(in UC, episcleritis>anterior uveitis)
what shows on a barium enema in crohns
kantor’s string sign
rose thorn ulcers
what does a biopsy show in crohns
skip lesions
deep ulcers
cobblestone appliance
transmural inflammation
non caveating granulomas
increased goblet cells
1st line treatment for crohns flare up
predinsiolone
treatment in crohns
induce remission:
prednisone / budesonide
maintain remission:
1st line: azathioprine (may cause myelosuppresion, reducing WCC)
2nd line: methotrexate
Bioogics
side effect of azothioprine
myelosuppression, may cause WCC reduction
next steps if crohns colonsoscipy is normal
investigate small bowwel by either
- small bowel capsule endoscopy
- MRI small bowel
what is proctitis
UC involving only rectum
what is pancolitis
UC involving entire colon
which parts of the gut can UC be found in
uptown the ileocaecal valve - never spreads proximally to this
does crohns or UC have genetic element, and what is the genetic element
UC
genetic predisposition - HLA-B27
rectal involvement in UC vs crohns
rectum is always involved in UC but often spared in crohns
what shows on a biopsy in UC
continuous inflammation
crypt abscesses
no granulomas
depletion of goblet cells
goblet cells in UC vs crohns
crohns: increase
UC: depletion
what shows on barium enema in UC
lead pipe appearance
AXR in UC
thumb printing
loss of haustra
pseudopolyps
toxic megacolon
toxic megacolon treatment
IV fluids
NBM
NGT
IV hydrocortisone –> surgery if don’t respond in 48-72 hrs
why do you need to monitor a pt on mesalazine with FBC
mesalazine causes agranulocytosis
no. of bowel movements in mild, moderate, severe UC
mild <4
moderate 4-6 (4 or 5)
severe 6 or more
treatment for UC
mild/moderate
- 5 -ASA (Mesalazine)
- topical for proctitis or proctosigmoiditis
- oral for more extensive disease or if topical doesn’t help
moderate flare up:
oral steroids
severe flare up
- 1st: IV hydrocortisone
- 2nd: IV cyclosporin
- 3rd: inflixamab
- 4th: colectomy
treatment for maintaining remision UC
1st: mesalazine
2nd: mercatopurine / azothioprine
what does MRCP show in primary sclerosing cholangitis
multiple beaded biliary structures
Tx for primary sclerosing cholangitis
supportive
liver transplant, but it can recur
antibodies shown in primary sclerosing cholangitis
ANA
p-ANCA
anti-SMA
what do LFTS indicate in primary sclerosing cholangitis
obstruction (v high ALP compared to ALT/AST)
what should symptoms of cholestasis (jaundice/ pruritis) in a pt with UC indicate
primary sclerosing cholangitis
first line / gold standard step of management for GORD
then following that what are the next steps
1) 8 week PPI trial
if this doesn’t work, or pt displays any ALARM symptoms (>55yrs, weight loss, dysphagia)
Do endoscopy
if endoscopy is negative
Do oesophageal manometry with pH monitoring
medication for GORD
PPI, can add H2 blocker (ranitidine) to this
Symptom relief med for GORD
antacids
PPI side effects
hypomagnesaemia
hyponatraemia (SIASH)
increased risk of C diff
osteoperosis + increased risk of fractures
what is the surgery for GORD
nissens fundoplication
2 types of oesophageal cancer
upper 2/3: squamous cell carcinoma
lower 1/3: adenocarcinoma
causes of squamous cell carcinoma of oesophagus
alcohol
smoking
HPV
hot beverages
diet low in fruit and veg
causes of adenocarcinoma of oesophagus
GORD
male sex
obesity
barrets oesophagus
hiatus hernia
first line gold standard investigation for oesophageal cancer
endoscopy and biopsy
investigation for oesophageal cancer
endoscopy + biopsy
CAP CT/MRI
(CAP = chest abdo pelvis)
treatment for oesophageal cancer
oesophagectomy + chemo
or
chemoradiotherapy
what is achalasia
decreased relaxation of LOS
gold standard investigation for achalasia
oesophageal manometry - shows increased LOS pressure
findings of barium enema in achalasia
birds beak appearance
how to stage oesphegal cancer
CAP CT / MRI
findings on CXR for achalasia
widened mediastinum
treatment for achalasia
pneumatic dilatation
hellers cardiomyotomy
2 signs of advanced disease in oesophageal cancer
hoarseness: compression of recurrent laryngeal nerve
horners syndrome: miosis, ptosis, anhidrosis
signs of upper GI bleed
haematemesis, meleana, raised urea
what is appendicitis caused by
obstruction of lumen of appendix, by faecolith, infective agents or lymphoid hyperplasia
what is mcburneys point of tenderness and what does it indicate
1/3 of distance from right ASIS to umbilicus
indicates appendicitis
what is rosvings sign and what does it indicate
deep palpation in LLQ elicits pain in RLQ
appendicitis
what is obturator sign and what does it indicate
pain on internal rotation of flexed hip
appendicitis
what is psoas sign and what does it indicate
pain on extension of hip
appendicitis or psoas abscess –> do CT abdo to check
what is blumberg sign and what does it indicate
rebound tenderness in RLQ
appendicitis
investigation for appendicitis
1st: FBC
CRP
abdo US
abdo CT (if US is inconclusive)
best imaging if appendix perforation is suspected
erect CXR
main FBC result in appendicitis
neutrophil associated leukocytosis
raised CRP
appendicitis treatment
laparoscopic appendicetocmy
give prophylactic ABx before surgery (metronidazole / cefuroxime)
2 main complications of appendicectomy
perforation –> peritonitis
pelvic abscess —> pain, fever, sweats, mucus diarrhoea
causes of acute pancreatitis
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion poison
Hypercalcaemia, Hypertriglyceridaemia
ERCP
Drugs
most common cause of acute pancreatitis in females
gallstones
most common cause of acute pancreatitis in males
alcohol
2 skin signs of severe pancreatitis
Cullens sign (periumbilical bruising)
Grey-turner sign (flank bruising)
describe the pain in acute pancreatitis
severe epigastric pain that radiates towards the back
sudden onset
worse with movement
what is the pH of body in acute pancreatitis
hypokalaemia metabolic alkalosis
(nausea and vomiting causes dehydration)
which enzyme do you test for in acute pancreatitis
lipase(more senssitive than lipase)
if suspect gallstones in acute pancreatitis what is the best imaging
ultrasound
leukocyte levels/results in acute pancreatitis
leukocytosis with left shift
what does elevated haematocrit (>44%) indicate in acute pancreatitis
poor prognosis
what does elevated ALT in acute pancreatitis indicate
suggests that gallstones is the cause
treatment for acute pancreatitis
Fluid resus
analgesia (IV morphine)
enteral feeding
treatment for gallstones pancreatitis
ERCP
what needs to be monitored very 6 months in chronic pancreatitis pts
HbA1c needs to be monitored very 6 months
as DM develops in majority of pts
faeces in chronic pancreatitis
steatorrhea
most sensitive test at detecting pancreatic calcification in chronic pancreatitis
CT
which enzyme is measured in chronic pancreatitis
faecal elastase
treatment for chronic pancreatitis
pancreatic enzyme supplements
most common form of pancreatic cancer
primary pancreatic ductal adenocarcinoma
signs and symptoms of pancreatic cancer
painless jaundice - suggests obstruction
dark urine and pale stools
pruritus
palpable mass in RUQ
non specific upper abdominal pain
weight loss and anorexia
which part of the pancreas is the cancer if it causes obstruction to bile flow
head of pancreas
cause of pruritic in pancreatic cancer
bile salts in circulation
cause of pale stool and dark urine in pancreatic cancer
pale stool: reduced stercobilinogen
dark urine: reduced urobilinogen, increased conjugated bilirubin
what does persistent back pain in pancreatic cancer suggest
retroperitoneal metastases
what is Courvoisier’s law
palpable gallbladder + obstructive jaundice –> malignancy, esp pancreatic malignancy
1st line investigation for pancreatic cancer and what does it show
and 2nd line
HRCT - shows “double duct sign” = dilation pancreatic and common bile ducts
if HRCT unavailable: abdo ultrasound
LFTs in pancreatic cancer
high
- bilirubin
- ALP
- GGT
normal
- ALT
biomarker for pancreatic cancer
CA 19-9
treatment for pancreatic cancer
whipple’s resection (pancreaticoduodenectomy)
–> for lesions at head of pancreas
+ adjuvant chemotherapy
side effects of Whipple’s resection
dumping syndrome
peptic ulcer disease
surgical treatment for pancreatic cancer that is just for palliation
ERCP with stunting
what is acute cholangitis
bacterial infection of biliary tract
what is the organism that most commonly causes acute cholngitis
E coli
2 main causes of cholangitis
choledocholelithiasis (gallstones in common bile duct)
Biliary strictures
what is Reynolds pentad
indicates obstrcutive ascending cholangitis:
RUQ pain
jaundice
fever
hypotension
altered mental state
what is charcots triad
RUQ pain
jaundice
fever
first line investigation for acute cholangitis
US scan
then first intervention is ERCP: helps to observe bile duct stone and can remove it too
how can LFTs differentiate between cholangitis and cholecystitis
high ALP+ALT suggest cholangitis rather than cholecystitis
ABG in sepsis
low bicarbonate
raised lactate
metabolic acidosis
MRCP vs ERCP
MRCP: just imaging
ERCP: imaging and therapeutic
possible side effect of ERCP
ERCP can cause pancreatitis
cholangitis vs cholecystitis
cholangitis = inflammation of bile duct
cholecystitis = inflammation of gallbladder
first line treatment for acute cholangitis
1st: IV antibiotics
2nd: ERCP drainage after 24-48 hrs
3rd: elective cholecystectomy (when pt is well to prevent further episodes)
factors for poor prognosis for acute cholangitis
hyperbilirubinaemia
high fever
leukocytosis
older age
hypoalbuminaemia
cause of cholecytitis
cystic duct obstruction caused by gallstones
cholecystitis risk factors
diabetes
TPN
gall bladder
signs and symptoms of cheolcytitis
RUQ pain
palpable mass
fever
positive Murphy’s sign (sudden pause on insipiration during deep palpation of RUQ due to pain)
right shoulder pain
nausea
vomiting
what is Murphy’s sign
sudden pause on insipiration during deep palpation of RUQ due to pain
first lien investigations for cholecyitis if sepsis is and is not suspected
sepsis not suspected: US
sepsis suspected: MRI/CT
what does US show in cholecystitis
thick gallbladder wall
treatment/management for cholecystitis and how soon after diagnosis should it be done
IV ABx + laparoscopic cholecystectomy (+ IV fluids + analgesia + NBM)
IV ABx is supportive
laparoscopic cholecystectomy should be done 1 week after diagnosis
risk factors for gallstones
5xFs
female
fat
forty
fertile
fair
OCP
rapid weight loss
sickle cell anameia (haemolytic conditions)
what are the 2 types of gallstones and what are they made of
cholesterol gallstones: cholesterol + calcium carbonate
pigment gallstones: calcium billirubinate (due to increased unconjugated bilirubin, associated with haemolytic diseases eg SCA)
what is the most common type of gallstone
cholesterol stones
signs and symptoms of biliary colic/gallstones
colikcy RUQ pain
can radiate to right scapula
pain after eating fatty meal
Murphy’s sign egtauve
no fever
nausea and vomiting
what is fever and LFT’s like in gallstones/biliary colic
no fever
normal LFTs
what is Murphy’s sign in biliary colic
negative
investigation for biliary colic
US (shows thin gallbladder wall)
if US negative but bile duct dilated or abnormal LFTs: MRCP
what does US show in biliary colic vs cholecystitis
biliary colic: thin gallbladder wall
cholecystitis: thick gallbladder wall
treatment for gallstones
analgesia
IV fluids
NBM
ERCP / electie laparoscopic cholecystectomy
if asymptomatic don’t need any treatment
what is the site of damage in primary biliary cholangitis
intrahepatic bile ducts
what do raised anti-michondrial antibodies indicate
primary biliary cholangitis
which cancer does primary biliary cholangitis significantly increase the risk of developing
hepatocellular carcinoma
which antibodies are see in sjogrens syndrome
anti Ro (SS-A)
ani La (SS-B)
rheumatoid factor
antinuclear
which cancer does primary sclerosing cholangitis significantly increase the risk of developing
cholangiocarcinoma
which antibodies are lily to be raised in primary scleroing cholangitis
anti-nuclear antibodies
what is sjogrens syndrome
autoimmune condition affecting parts of the body that produce fluids
symptoms include dryness
psc vs pbc
btw are autoimmune cholestatic liver diseases
psc:
- targets medium/large extra hepatic and intrahepatic bile ducts
- associated with IBD/colon cancer/bile duct cancer
- roughly equal M:F
- diagnosed by MRI of blue ducts
- usually not associated with smoking history
- itching, fatigue, abdo pain
- antibodies = ANA, ASMA
pbc:
- targets small intrahepatic bile ducts
- not associated with IBD/colon cancer/bile duct cancer
- F > M
- diagnosed by raised AMA / ALP
- associated with smoking history
- itching, fatigue abdo pain, dry eyes and mouth
- antibodies = AMA
what is Whipple’s disease
chronic infectious disease - bacterial infection, affects joints and digestive system
which pt demographic does Whipple’s disease mostly present in
middle aged white men
triad of Whipple’s disease
dementia, ophthalmoplegia, myoclonus
gold standard investigation for diagnosis of whipples disease
jejunal biopsy
what does a jejunal biopsy for whipples disease show
stunted villi
deposition of macrophages in lamina proprietor
stains positive for PAS (period acid-Schiff)
what is zollinger Ellison syndrome
gastric secreting tumour / hyperplasia of islet ells causes overproduction of gastric acid
–> results in recurrent peptic ulcers
can pancreatic cancer present with abdominal pain
yes, if in body or tail of pancreas - head of pancreas presents as painless jaundice
which syndrome causes a pancreatic cancer which presents with recurrent peptic ulcers and diarrhoea
zollinger Ellison syndrome
presentation of cholangiocarcinoma
overt jaundice
no abdo pain
how does typhoid fever present
abdo pain
weekness
headaches
rose spot rashes
how is typhoid fever transmitted
faecal oral route
what is the likely diagnosis of explosive non-bloody/mucus diarrhoea, ons 1 week after trying local food abroad
giardiasis
what is the likely diagnosis of watery diarrhoea, abdominal cramps, dehydration after taking clindamycin
C diff infection
3 risk factors for C diff infection
recent abx: clindamycin / penicillin
age over 65
prolonged stay in healthcare setting
what is used to treat chemo-related nausea and vomiting
5HT3 antagonist
what is functional dyspepsia
recurring symptoms of upset stomach with no obvious cause
- burning stomach pain
- bloating
- heartburn
- nausea
- vomiting
- burning
which drug is sued for cytotoxic induced nausea and vomiting
Ondanestron ( 5HT antagonist)
what is mirizzi’s syndrome
gallstone impacted at the neck/infundibulum of gallbladder
what is a gallbladder muocoele
accumulate of bile in gallbladder due to blockage of cystic duct, usually by gallstone
what is the calcium levels of pts with malignancies
hypercalcaemia
what is the glucose level in pancreatic cancer
raised serum glucose (may present as impaired glucose tolerance or diabetes) as the endocrine function of the pancreas becomes damaged
what causes achalasia
progressive degeneration of the ganglion cells in the myenteric Lexus - causes failure of relaxation of the LOS
which 2 common meds can cause dyspepsia
NSAIDs and aspirin
what is ‘multiple beaded biliary structures on MRCP’ seen in
primary sclerosis cholangitis
which class of antibody is raised in serum of PBC pts
IgM
what is portal hypertensive gastropathy
changes in the stomachs lining caused by elevated blood pressure in the portal vein
what does biopsy show in PSC vs PBC
PSC: onion skin fibrosis
PBC: granulomas
indications for TIPS
refractory ascites
budd-chiari syndrome
oesophageal variceal bleed
first line treatment for giardiasis
metronidazole
cholangiocarinoma vs pancreatico cancer symptoms
cholangiocarcinoma: biliary colic, jaundice
pancreatic cancer: painless jaundice
what should painless jaundice raise a high suspicion of
pancreatic cancer
if a pt has barrets oesophagus but no dysphasia, how often should they have endoscopic surveillance?
every 3-5 years
what is it common for pts to expect for upto 6 weeks following treatment for giardiasis
lactose intolerance
which condition does the triad of dysphagia, iron deficiency anaemia and glossitis indicate
Plummer vinson syndrome
what is mallory Weiss syndrome
oesophageal tear secondary to severe vomiting which leads to haematemesis
common in alcoholics
what type of stool does cholera vs giardiaisis cause
cholera: explosive ‘rice water’ stool
giardiasis: explosive fatty stool
which condition should metoclopramide be avoided in
parkinsons
which anti emetic should be avoided in bowel obstruction
metoclopramide
what fluid rhesus is needed for a pt with acute pancreatitis
IV crystalloid given 4-6 hourly
are colloid or crystalloid IV fluids used more
crystalloid
colloid fluids are generally not used bc of risk of anaphylaxis
contrast dysphagia due to anatomical causes and oesophageal motility causes
anatomical causes: difficulty swallowing solids first and then liquids
oesophageal motility causes: difficulty swallowing liquids first and then solids
what is a likely diagnosis of. apt with dysphagia first to solids and then to liquids, painful hands, telengiechtasia and positive anti-centromere antibodies
limited cutaneous systemic sclerosis (CREST syndrome)
what is the cause of dysphagia with eosinophil infiltration of mucosa on oesophageal biopsy
eosinophilic oesophagitis
what is the cause of dysphagia with upper oesophageal web on endoscopy, iron deficiency anaemia, glossitis, angular stomatitis
Plummer vinson syndrome
what is a common side effect of canaglifozin
balanoposthitis
what re-testing method is recommended for Hpylori after completing eradication therapy
urea breath test
most likely diagnosis of pt with diarrhoea, weight loss hyperpigmentation of skin, polyarthralgia
whipple’s disease
gold standard diagnosis of whipples disease
jejunal biopsy - stunted villi, deposition of macropjages in lamina propria which stain positive for PAS (period acid-schiff)
Tx for Whipple’s disease
ABx - cotrimoxazole
what is the criteria for urgent endoscopy
over 55 with weight loss
plus
reflux, dyspepsia or abdo pain
what is a likely cause of dysphagia, regurgitation and halitosis
pharyngeal pouch (zenker’s diverticulum)
which cancer is trousseau syndrome associated with
pancreatic cancer
which cancer is Lambert eaton myasthenic syndrome (LAMS) associated with
small cell lung cancer
what are acetylcholine receptor antibodies specific for
myasthenia gravis
what antibodies are found in PBC
antimitochondrial antibodies (AMA)
what antibodies are found in PSC
antineutrophil cytoplasmic antibodies (ANCA) (esp p-ANCA)
anti smooth muscle antibodies (SMA)
what is the likely diagnosis if a sjogrens syndrome pt presents with fatigue and skin itchiness with raised ALP
primary biliary cholangitis
drugs which induce pancreatitis
FAT SHEEP
F-Furosemide (lasix)
A-Asa, AZT, Asaparaginase
T-Tetracyclines
S-Statins, (sulfonamides), Steroids
H-HCTZ
E-Estrogens (OCP)
E-EtOH
P-Pentamidine
what do you first need to rule out if a 15 year old girl comes in with abdominal pain
ectopic pregnancy
what is Trousseau’s sign
migratory thrombophlebitis - associated with pancreatic cancer
what 2 signs are associated with pancreatic cancer
Courvoisier’s sign: painless palatable gallbladder + jaundice
Trousseau’s sign: migratory thrombophlebitis
which pt group does PBC most present in
women
what is the first line treatment fro cholestatitic pruritus
cholestyramine
most common type of oesophageal cancer in GORD pts
adenocarcinoma
TIPSS procedure diverts some blood flow way from the liver parenchyma, what is a complication of this procedure?
hepatic encephalopathy
what is a perineal abscess
a pus collection in the perineal region
what is a perineal fistula
a chronically infected tract between the rectum and perineum
at which stages do abscess and fistulas form in purulent perineal infections
abscess: acute manifestation
fistula: chronic manifestation
main cause of perineal asbcesses and fistulas
flow obstruction and bacterial infection of the anal crypt glands
contrast symptoms of perineal abscess and fistula
abscess: dull pain, pruritis
fistula: constant, throbbing pain
best ix to visualise a perineal fistula’s course
MRI pelvis
confirmatory tests for deeper perineal abscesses
MRI/CT
anal ultrasonography
treatment and post operative care for perineal abscess
Tx:
surgical incision and drainage
post operative care:
sitz bath
analgesics
stool softeners
abx for immunocompromised
treatment for normal perineal fistula
surgical fistulotomy (cut along the whole fistula to open and drain it)
treatment for complex perineal fistula
seton placement (surgical thread placed through fistula to keep it open and allow it to be drained - stops pus forming and it healing around the pus, as that will cause other abscesses to form)
which 2 classes of medications are risk factors for C diff
abx
PPIs
which 4 antibiotics are risk factors for c diff
4 x C
clarithromycin
clindamycin
ciprofloxacin
cephalosporin
what shows on a sigmoidoscopy for infectious colitis
yellow plaques
if infectious colitis causes perforation what can this lead to
toxic megacolon
symptoms for infectious colitis
possible mucus and blood in diarrhoea
fever
lower abdo pain
malaise
what does a positive antigen stool sample for C diff indicate
indicates bacterial exposure but not necessarily current infection
Tx for infectious colitis
hydration
loperamide (antidiarrhoeals)
Abx
Tx for C diff
10 days course of oral vancomycin
what are colonic diverticula
outpouchings of the colonic mucosa
which meds can be risk factors for diverticulitis
NSAIDs and opioid
Risk factors for diverticulitis
age > 50
low dietary fibre
constipation
diet rich in salt, meat, sugar
obesity
NSAID and opioid used
smoking
symptoms for diverticulitis
LLQ pain
constipation / change in bowel habits
rectal bleeding
N & V
fever
what does leukocytosis in someone with diverticula suggest
acute diverticulitis, if have symptoms too
which scan is used for someone with suspected acute diverticulitis and raised inflammatory markers
contrast CT of abdo
how does diverticulitis look on barium enema
saw tooth pattern
what does riglers sign indicate on X-ray
(double walled gut is visible) - indicates air in the abdo (pneumoperitoneum) which could be due to gut perforation
treatment for asymptomatic diverticulosis
dietary and lifestyle modifications
treatment for acute and uncomplicated diverticulitis, and then what do u do if complications arise
oral abx and analgesia
if not responding after 72 hrs give IV abx (ceftriaxone + metranidazole)
if complications do Hartmanns procedure (resection of rectosigmoid colon and end colostomy is formed)
what does pneumaturia and faecaluria indicate
colovesical fistula
what does vaginal passage of faeces or flatus indicate
colovaginal fistula
what are the 2 types of bowel obstruction
Functional ie no peristalsis - paralytic ileus
Mechanical ie a physical obstruction - SBO or LBO
contrast the clinical and examination features of mechanical vs functional obstruction
mechanical:
- colicky pain
- tinkling bowel sounds, then absent
- peristalsis
- dilated bowel proximal to obstruction
- clear obstruction on scan
- no air in rectum - collapsed bowel and rectum distal to obstruction
functional:
- diffuse continuous pain
- no bowel sounds
- no peristalsis
- whole bowel is diffusely, equally dilated
- no obstruction on scan
- air in rectum
what causes functional bowel obstruction
paralytic ileus, which can happen after bowel surgery
what is the max the SB, LB and caecum can dilate to
3 cm
6 cm
9 cm
contrast causes of SBO and LBO
SBO
hernias
adhesions
gallstones
LBO
tumour
volvulus
diverticulitis
contrast the clinical signs of SBO vs LBO
SBO
early bilious vomiting
late constipation, esp if proximal obstruction
less severe abdo distention
LBO
late vomiting
faecal vomiting
early constipation
early and significant abdo distention
what obstruction does faecal vomiting indicate
LBO
contrast SBO and LBO on imaging
SBO
max 3cm dilated
valvular conniventes (lines go all way across)
central dilated loops
LBO
max 6cm dilated
haustra (lines don’t go all way across)
peripherally dilated loops
1st line Ix for bowel obstruction
abdo xray
gold standard diagnostic Ix for bowel obstruction
CTAP with IV contrast
treatment for bowel obstruction
IV fluid resus
NBM
NGT decompression
analgesia
anti emetics
electrolyte replacement
surgery
what should you monitor during post operative paralytic ileus
U&Es
(as electrolyte imbalance can contribute to ileus)
acid base level in vomiting
hypokalaemia metabolic alkalosis
acid base level in bowel ischameia
metabolic acidosis
what 2 things in bloods indicate bowel ischameia
raised lactate
leukocytosis
what are the most common sites of volvulus in adults
sigmoid colon
caecum
contrast RFs for sigmoid volvulus and caecum volvulus
sigmoid:
older pts
chronic constipation
chagas disease
neurological conditions
psychiatric conditions
caceal:
all ages
adhesions
pregnancy
which volvulus happen more in older pts
sigmoid
where does volvulus happen in infants
midgut
symptoms of volvulus
similar to bowel obstruction symptoms
abdo pain which decreases after explosive passage of stool or gas
distension
bililous vomiting
what does failure to pass NG tube, epigastric pain and vomiting indicate
gastric volvulus
what does bilious vomiting, haematochezia. haematomesis, hypotension and tachycardia in an infant indicate
midget volvulus
how does sigmoid volvulus present on X-ray
coffee bean sign
2 dilated loops
LBO
how does cecal volvulus present on X-ray
kidney bean/embryo sign
1 dilated loop
SBO
how does volvulus present on CT
whirl sign
how does volvulus present on barium enema
birds beak sign
Surgery for sigmoid volvulus
rigid sigmoidoscopy with rectal tube insertion (detorsion)
Surgery for sigmoid volvulus if peritonitis or decompression doesn’t work
sigmoid colectomy (take out sigmoid colon and anastamose with rectum
–> haemodynamically stable pt with viable bowel
Hartmanns procedure (signed is removed, end colectomy is formed)
–> haemodynamically unstable pt with ischaemic bowel
surgery for cecal volvulus
right hemicolectomy
Surgery for intestinal malrotation (midgut volvulus in infants)
Ladd procedure
what type of cancer are the majority of colorectal tumours
adenocarcinomas
contrast features/symptoms of right, left and rectal colorectal tumours
right sided
- melaena / occult
- iron deficiency anaemia
- diarrhoea
left sided
- changes in bowel habits
- streaks of blood
- colicky pain
rectal
- tenesumus
- flatulence
- faceal incontimnece
- haematochezia
- rectal pain
what medication should pts take before colonoscopy
laxatives
diagnostic Ix for colorectal tumours
colonoscopy and biopsy
Ix to stage colorectal cancer via dukes staging
CT CAP
what are Duke’s A-D of colorectal cancer
Dukes A - tumour confined to the mucosa
Dukes B - tumour invaded past the mucosa and thriough the bowel wall
Dukes C - lymph node metastases
Dukes D - distant metastases
how does colorectal tumour look on barium enema
apple core lesion (due to stricturing)
how to monitor disease progression for colorectal tumours
measure CEA - tumour marker
screening for colorectal tumours
FIT test every 2 years for men and women aged 60-74
criteria for 2 WW referral for colorectal tumour suspicion
60 years or older with
iron deficiency anaemia
or
change in bowel habit
resection and anatomises for cecal, ascending or proximal transverse colon
right hemicolectomy
ileo-colic
resection and anatomises for distal, transverse, descending colon
left hemicolectomy
colo-colon
resection and anatomises for sigmoid colon
higher anterior resection
colo-rectal
resection and anatomises for upper rectum
anterior resection (TME)
colo rectal
resection and anatomises for low rectum
anterior resection (low TME)
colo rectal
resection and anatomises for anal verge
abdomino perineal excision of rectum
none
signs/symptoms of anastomotic leak?
diffuse abdo tenderness
tachycardia
rigidity
tachycardia
hypotensive
contrast direct and indirect inguinal hernia
direct
- medial to inferior epigastric vessels
- through posterior wall of inguinal canal
- due to straining / weakness in abdo wall muscles
- older men
indirect
- lateral to inferior epigastric vessels
- through deep inguinal ring into inguinal canal
- due to abdo wall defects present from birth
- infants
contrast inguinal and femoral Hernia
inguinal
- supermedial to pubic tubercle
- reducible
- cough impulse present
femoral
- inferolateral to pubic tubercle
- non reducible
- cough impulse absent
what is hasselbachs triad and which hernia occurs here
between
- inferior epigastric vessels
- rectus border
- inguinal ligament
direct inguinal hernia
investigations for hernia
groin ultrasound
Ct abdo - for obese pts
what does raised lactate and leukocytosis indicate in context of hernia
strangulation
- ischaemia
treatment of hernia if pt is medically fit
if pt is medically fit always do surgical mesh repair
treatment for inguinal hernia if pt is not medically fit for surgery
Truss support belt
what type of groin hernia should always be treated surgically due to strangulation
femoral hernia
contrast an incarcerated and a strangulated hernia
incarcerated
- just trapped
- pain
- no systemic symptoms
strangulated
- blood supply cut off
- pain
- systemic symptoms eg absent bowel sounds, tender and distended abdo
contrast a rolling and sliding hiatus hernia
sliding
- GOJ moves above diaphragm
rolling
- GOJ stays below diaphragm but another part of stomach eg fungus moves above diaphragm
which hiatus hernia requires more urgent surgical intervention due to volvulus risk
rolling hiatus hernia
symptoms for hiatus hernia
hiccups
GORD symptoms
heartburn
regurgitation
dysphagia
odnophagia
cough
chest pain
SOB
medical and surgical treatment for hiatus hernia
weight loss and 4-8 weeks PPI
surgery (mainly for rolling hiatus hernia) : Nissens fundoplication and hiatoplasty
most sensitive investigation for hiatus hernia
barium swallow
first line investigation for hiatus hernia
upper GI endoscopy
- due to symptoms most pt have this endoscopy and the hernia is found incidentally
what is seen on a CXR with hiatus hernia
retrocardiac bubble
what are peptic ulcers caused by
gastric acid
pepsin
which layer of the GI wall do peptic ulcers reach to
submucosa
what is the most common peptic ulcer, gastric or duodenal
duodenal
what are the most common causes of peptic ulcers
NSAIDs
H pylori
which type of peptic ulcer is more common in older people (50+)
gastric
which type of peptic ulcer is more common in young people (30)
duodenal
contrast pain and weight changes in gastric and duodenal ulcers
gastric
- pain immediately after eating
- weight loss
duodenal
- pain a couple hours after eating
- eating may a make pain better
- weight gain
what kind of pain is seen in peptic ulcers
epigastric “gnawing” pain
what is gastritis
mucosal inflammation of GI tract
symptoms of gastritis
nausea
vomiting
loss of appetite
weight losss
gold standard diagnostic test for peptic ulcer disease
upper Gi endoscopy
2 tests for H pylori
carbon 13 urea breath test
stool antigen tests
which tests for H pylori can be used post eradication therapy
carbon 13 urea breath test
what does CXR show in perforated gastric vs perforated duodenal ulcer
perforated gastric ulcer
- dome sign
perforated duodenal ucler
- pneumoperitoneum
what does raised urea indicate
UPPER GI bleed as opposed to lower GI
management plan for peptic ulcer disease in a H pylori positive vs negative pt
universal
- reduce smoking and alcohol
positive H pylori
- triple eradication therapy for 1 week, twice daily (omeprazole, clarithromycin, amoxicillin - or metranidazole if penicillin allergy)
negative H pylori
- stop drug causing ulcer eg NSAIDS
- omeprazole 20mg for 4-8 weeks
- gastric ulcer - repeat endoscopy 6-8 weeks later
- duodenal ulcer - repeat carbon 13 urea breath test for H pylori 6-8 weeks later
what is the next step if a patient with peptic ulcer disease is H pylori positive and their symptoms don’t improve after triple eradication therapy
endoscopy
contrast boerrhaves tear and mallory-weise tear
Boerrhaves tear - TEARS ALL THE WAY THROUGH
- transmural
- distal 1/3 of oesophagus
- severe sudden onset chest pain following repeated episodes of vomiting (and prolonged alcohol use)
- subcutaneous emphysema
- progresses to chest and neck pain and dysphagia
mallory weiss tear - VOMIT BLOOD, DOESNT TEAR ALL THE WAY THROUGH
- confined to mucosal membrane (mucosa and submucosa)
- haematemssis
contrast the pain in gastroduodenal vs large bowel perforation
gastroduodenal
- epigatrsic pain
large bowel
- peritonitic abdo pain
first line investigation for GI perforation
erect CXR
will see pneumoperitoenum
gold standard investigation for bowel perforation
CT with Iv contrast
what does riggler’s sign indicate on AXR
GI perforation
- double walled sign due to gas outlining both sides of the bowel
what investigation is used specifically for oesophageal perforations
gastrograffin swallow
surgical repair of large bowel perforation
hartmanns procedure - resection of the perforated section
peritoneal lavage
surgical repair of gastroduodenal perforation
perforation is closed with omental patch
do gastric or duodenal ulcers have higher morbidity / mortality
gastric
most common pathogen cause of peritonitis
e coli
most likely diagnosis if a pt with ascites secondary to liver failure presents with fever and abdo pain
SBP
diagnostic test for SBP
paracentesis / ascitic tap
SBP if neutrophils > 250 / mm3
2 investigations for peritonitis
paracentesis / ascitic tap - check neutrophil count for SBP
ascitic fluid culture - determine causative organism
management for peritonitis
empirical IV antibiotics (cefotaxime)
IV albumin
management for peritonitis if protein conc < 15 g/L or previous episode of SBP
continuous abx prophylaxis ( oral ciprofloxacin / norfloxacin)
what is mesenteric adenitis
inflammation of lymph nodes in abdominal mesentery
most common cause of mesenteric adenines
recent viral intestinal infection
which condition can mesenteric adenitis mimic
appendicitis - usually has RLQ pain
which pts does mesenteric adenines commonly affect
children and teenagers
Ix for mesenteric adenitis
abdo ultrasound
bloods
Tx for mesenteric adenitis
self limiting
fluids
paracetamol / ibuprofen
abx if caused by bacterial infection
2 example causes of malabsorption
coeliac disease
IBD
2 example causes of maldigestion
exocrine pancreatic insufficiency
orlistat use
an example cause of global malabsorption
coeliac disease
an example cause of partial malabsorption
vit B12 deficiency due to problems in terminal ileum
deficiency of what causes alopecia and wound healing problems
zinc
deficiency of what causes bleeding tendency
vit K
deficiency of what causes oedema
protein
deficiency of what causes muscle weakness
potassium
deficiency of what causes tetany
calcium
deficiency of what causes goitre
iodine
what is a D-Xylose absorption test
tests absorptive ability of upper small intestine
treatment for malabsorption
oral supplementation
calorie and protein enriched diet
Iv nutrition in severe cases
define malnutrition
BMI < 18.5
or
weight loss of > 10% in 3-6 months
or
BMI < 20 and weight loss of > 5% in 3-6 months
screening test for malnutrition and what does it measure
MUST
uses BMI, recent weight change and acute disease to categorise pts in high medium and low risk
treatment for malnutrition
1st: ‘food-first diet’ (a nutrient dense diet)
then give ONS (oral nutritional supplements) - taken between meals
if that doesn’t work - feeding tube (enteral nutrition)
for more severe cases -parenteral nutrition (IV - doesn’t go through Gi tract)
side effect of enteral nutrition
diarrhoea
what is refeeding syndrome and how can it be avoided
effect of nutrition following starvation - electrolyte imbalances
hypophosphataemia, hypomagnaseamia (can cause torsades des pointes) , hypokalaemia
avoided by: if pt hasn’t eaten for 5+ days, give less than 50% of what they’re meant to receive for first 2 days
which population has high incidence of gastric cancer
asia
most common form and location of gastric cancer
adenocarcinoma
lesser curvature of stomach
main 4 RF for gastric cancer
diet high in nitrates or salts
h pylori
smoking
pernicious anaemia
what is pernicious anaemia
autoantibodies attack gastric parietal cells causing deficiency in If and vit B 12
symptoms of gastric cancer
epigastric pain
dyspepsia
weight loss
skin sign related to gastric cancer
acanthosis nigricans - smooth brown velvety symmetrical patches on skin
sign of lymphadenopathy or metastases in gastric cancer
virchows node
- left supraclavicular region
saint Mary josephs nodule
- umbilical region
krukenberg tumour
- ovarian mass
an ovarian mass is a rare presentation of which cancer metastases
gastric cancer
1st line Ix for gastric cancer
upper Gi endoscopy with biopsy
what is seen in biopsy for upper GI endoscopy of gastric cancer
signet ring cells
Ix for gastric cancer staging
Ct CAP
endoscopic ultrasound with FNA is an alternative
MRI is used to see spread to liver
what should you monitor after someone has gastrectomy for gastric cancer, and why
vit B12
can cause neurological symptoms
2 situations which require 2 ww referral for OGD
dysphagia at any age
or
=> 55 yrs with weight loss + abdo pain / reflux / dyspepsia
main 3 causes of viral gastroenteritis in order of how common
norovirus
sapovirus
rota virus
main 3 causes of bacterial gastroenteritis
campylobacter
e coli
salmonella
which ages does norovirus affect
all ages
which viruses causing gastroenteritis affect younger children
rota virus
astrovirus
adenovirus
which virus causing gastroenteritis has a longer incubation period (8-10 days) compared to others
adenovirus
which virus causing gastroenteritis causes periodic diarrhoea that lasts over 10 days
adenovirus
how does CMV present
colitis, ulceration
which pts does CMV commonly affect
immunocompromised
which virus causing gastroenteritis is spread via bodily fluids or transplanted organs/ transfused blood
CMV
blood and mucus in stool
fever
malaise
dehydration
sudden onset diarrhoea
N& V
diagnosis ?
bacterial/viral gastroenteritis
what can norovirus cause in frail pts (it is self limiting in healthy pts)
pre renal acute kidney injury
meds for C diff
oral vancomycin
add metronidazole if severe
what can campylobacter cause
Guillain barre syndrome
what is Guillain barre syndrome
autoimmune demyelinating polyneuropathy affecting pns
1st sign of Guillain barre syndrome
leg pain / weakness
signs and symptoms of Guillain barre syndrome
leg pain / weakness
ascending weakness
AREFLEXIA
resp muscle weakness –> resp failure
2 Ix for Guillain barre syndrome
lumbar puncture: CSF = high protein (autoantibodies), normal WCC
nerve conduction study: decreased motor nerve conduction
Tx for Guillain barre syndrome
IV Ig (normal abs dilute auto abs)
plasmapheresis (filter auto abs from plasma)
What is lynch syndrome also known as
Hereditary nonpolyposis colorectal cancer (HNPCC)
Which bacteria causes gastroenteritis when food esp rice is not immediately refrigerated after cooking
Bacillus cereus
Incubation. Period of campylobacter
2-5 days
Most common cause of bacterial diarrhoea
Campylobacter
Initial management for variceal bleeding
Antibiotics
Terlipressin / somatostatin (vasoconstrictors)
Definitive management of variceal bleeding
Variceal band ligation
What is given to reverse anticoagulant medication pre endoscopy
Prothrombin complex concentrates
First line treatment for pt with haematemesis and melaena (ie acute non variceal upper GI bleed)
Endoscopic treatment
Most definitive investigation for pharyngeal pouch
Barium swallow
Likely diagnosis of a left sided mass in neck with gurgling sound on palpating, and pt experiences regurgitation
Pharyngeal pouch
Which cancer is H pylori strongly associated with
MALT lymphoma
Which condition causes freckles in lips, hands, soles of feet and increases risk of gastric cancer
Peutz Jeghers syndrome
What is Rockall score used to measure
Severity of GI bleeding
What is child Pugh score used to measure
Cirrhosis
What is Glasgow score used to measure
Acute pancreatitis
What is HAS-BLED score used to measure
risk of bleeding in pts taking anticoagulants for atrial fibrillation - score of 3+ suggests high risk of bleeding
What should pts at high risk of refereeing syndrome be started on
Thiamine of pabrinex
What are the 4 Ds of pellagra (vit B3 deficiency)
Dementia
Diarrhoea
Dermatitis
Death (if not treated promptly)
What nutritional deficiency causes pellagra
Vit B3
What nutritional deficiency causes beriberi
Thiamine
What nutritional deficiency causes xerophthalmia
Vit A
Contrast wet and dry Beriberi
Wet beriberi - Herat failure and peripheral oedema
Dry Berberi - peripheral neuropathy
Tx from beri beri
IV pabrinex then oral thiamine
Tx for scurvy
Absorbic acid
Features of scurvy
Cachexia
Gingivitis
Halitosis
Gut / bladder / gum bleeding
Oedema
Effect of grapefruit juice on cytochrome p450 enzymes
Inhibitor
Effect of rifampicin on cytochrome p450 enzymes
Inducer
Effect of clarithromycin on cytochrome p450 enzymes
Inhibitor
Which condition requires regulate venesection / phlebotomy
Hereditary haemachromatosis
Likely Diagnosis: fever, abdo pain, rash in trunk
Typhoid fever
What is zollinger Ellison syndrome
Neuro endocrine tumour which secrets gastrin
if a pt is having UC flare up and isn’t improving on topical and oral ASA what do you do
ADD oral prednisolone to the ASA
